All posts by TheTraumaPro

Best Practice: Use of CT Scan In Trauma Activations – Part 2

In my last post, I described how the unscheduled and random use of CT scan in trauma activations can interfere with normal radiology department workflow, creating access problems for other emergency and elective patients. Today, I’ll detail a project implemented at my hospital to analyze the magnitude of this problem and try to resolve it.

We started with a detailed analysis of how the scanner was being used for trauma activation patients. Regions Hospital has a single-tier trauma activation system, with no mechanism of injury criteria other than penetrating injury to the head, neck, and torso. There are usually about 850 activations per year, and traditionally the CT scanner has been “locked down” when the activation is announced. The CT techs would complete the current study on the table, then hold the scanner open until called or released by the trauma team.

Since we are a predominantly blunt trauma institution, we scan most stable patients. Our average time in the trauma bay is a bit less than 20 minutes. Add this time to the trauma activation prenotification time of up to 10 minutes, and the scanner has the potential to sit idle for up to half an hour. And in some cases when scan is not needed (minor injuries, rapid transport to OR) the techs were not notified and were not aware they could continue scanning their scheduled cases.

A multidisciplinary group was created and started with direct observation of the trauma activation process and a review of chart documentation and radiology logs. On average it was calculated that the scanner was held idle for an average of 17.9 minutes too long. This is more than enough time to complete one, or even two studies!

A new process was implemented that required the trauma team leader to call out to the ED clerk placing orders for the resuscitation 5 minutes before the patient would be ready for scan. I still remember the first time this happened to me. I was so used to just packing up and heading to scan, I got a little irritated when told that I hadn’t made the 5-minute call. But it’s a good feedback loop, and I never forgot again!

We studied our workflow and results over a 9-week period. And here are the factoids:

  • The average CT idle time for trauma activations before the project was 17.9 minutes
  • This decreased to an average idle time of 6.4 minutes during the pilot project
  • Total idle time for all activations was 8.3 hours, but would have been 36 hours under the old system
  • A total of 28.6 hours were freed up, which allowed an additional 114 patients to be scanned while waiting for the trauma activation patients

This was deemed a success, and the 5-minute rule is now part of the routine flow of our trauma activations. We rarely ever have to wait for CT, and if we do it’s usually due to the team leader not thinking ahead.

Bottom line: This illustrates the processes that should be used when a quality problem surfaces in your program:

  • Recognize that there is a problem
  • Convene a small group of experts to consider the nuances
  • Generate objective data that describes the problem in detail
  • Put on your thinking caps to come up with creative solutions
  • Test the solutions until you find one that shows the desired improvement
  • Be prepared to modify your new systems over time to ensure they continue to meet your needs

Best Practice: Use of CT Scan In Trauma Activations – Part 1

Computed tomography is an essential part of the diagnostic workup for many trauma patients. However, it’s a limited resource in most hospitals. Only so many scanners are affordable and available.  Typically, trauma centers have a scanner located in or very near the trauma bay, which makes physical access easy. Others may be located farther away, which can pose logistical and safety issues for critically injured patients.

Even if the CT is close to the ED, availability can be an issue. This availability applies not only to trauma scans, but to others as well. There is an expectation that CT be immediately available when needed for trauma activation patients. However, chances are that the same scanner is also used for high priority scans for services other than trauma, such as stroke evaluation.

Who gets the scanner first? Obviously, many trauma patients need rapid diagnosis for treatment of their serious injuries. But a fresh stroke patient also has a neurologic recovery countdown clock running if they might be eligible for lytic administration.

And don’t forget that trauma and stroke aren’t the only services vying for that scanner. The hospital undoubtedly has a stream of elective scans queued up for other in-house patients. Every urgent or emergent scan needed for trauma sets the elective schedule back another 30 minutes or more.

How does your trauma center manage CT scan usage for trauma? The vast majority essentially lock it down at some fixed point. This is typically either upon trauma activation, or at patient arrival. The former is very common, but also very wasteful because there can be a significant wait for the patient to actually arrive. Then add on the time it takes to complete the trauma bay evaluation. Up to an hour may pass, with no throughput in the CT scanner. This can be a major work flow headache for your radiology department.

Is there another way? My center was one of those that stopped the scanner after the current patient was finished at the time the trauma activation was called. We have two scanners just 30 feet from the trauma bays, so one could continue working while the other was held. However, this cut their throughput by 50% for roughly half an hour. We recognized that this was a creating a problem for the whole hospital, so we worked with the radiology department to come up with a better way.

Tomorrow I’ll detail the new system we implemented, and provide data showing the real impact of this new system on CT scan productivity.

What The Heck? CT Imaging Problem: The Answer

I received some good guesses about this image yesterday, but no one got the right answer.

The patient had sustained blunt trauma and was undergoing CT imaging. The scout for the abdominal CT showed some kind of weird debris that interfered with the image, but when we uncovered and looked at the patient, nothing was visible:

What the heck? If you look carefully at the left side of the image, you can see that the “debris field” is on the surface of the patient. We can’t see in 3-D on images, but the difference in appearance on the left and right sides looks like it this stuff is wrapping around the patient.

She was brought in by EMS with a warming blanket in place. On closer inspection, this was a thin, disposable blanket that heats up when removed from an airtight plastic pouch. These blankets contain thin pockets of a mineral mixture that looks like gravel. When exposed to air it heats up.

But on CT it looks like bone density material! When we looked at the patient, we were just lifting off the blanket that contained the offending material. Hence, we couldn’t find it.

Here’s a picture of one of these products. Note the six mineral pouches embedded in it., Don’t let this happen to you!

 

What The Heck? CT Imaging Problem

Here’s one for you. A patient is brought to you after a motor vehicle crash. You’ve completed your evaluation in the trauma resuscitation room, and you move off to CT for some imaging.

As the techs are preparing to do the abdominal CT, they perform the scout image to set up the study. This is what you see:

The arm was left down due to a fracture (note the splint along the forearm). But what is all that debris on the image? Other than a few abrasions here and there, nothing is visible on the skin in those areas.

What the heck? What do you think these are? Will they interfere with imaging? And what can you do about it?

Tweet or comment with your answers. I will explain all tomorrow.

Zebra Alert: Blunt Injury To The Thoracic Duct

Today I’m going to review a very uncommon clinical problem in trauma: injury to the thoracic duct. To review, the lymphatic system coalesces into channels along the spine. These vessels travel upwards to drain into the venous system as the left and right lymphatic ducts. The exact drainage points vary, but are near the junctions of the internal jugular and subclavian veins bilaterally. Technically the larger of the two, the left lymphatic duct, is termed the thoracic duct. However, injuries can occur on either side.

Injuries to the lymphatic ducts are very rare due to their small size and their protection by surrounding structures and tissues. For this reason, the literature on this topic consists almost exclusively of case reports. Injury can occur from direct penetration by gunshots or stabs, or may be associated with high energy blunt trauma. It has also been reported to occur in cases of multiple posterior rib fractures and vertebral fractures.

In the rare event that these ducts are damaged, they pose a major management problem because lymph does not clot. These vessels are not self-sealing like most others in the body. They will only close through healing (scarring) or by ligation. The typical disruption occurs near the junction of the duct with the venous system, so lymph (chyle) typically accumulates in the thorax on the affected side. This results in a hydrothorax until the patient begins eating, when it turns chylous and makes the diagnosis easy. Here a various shades of chyle that you might see in the chest tube drainage.

If in doubt, triglyceride levels can be measured, and a value greater than 110 mg/dL is considered positive.

Initial management is usually dietary, via reduction in fat intake to render the drainage clear. This may be accomplished by a low fat diet or by TPN. I don’t really buy the effectiveness of this, since the fat content is not what causes the leak to persist. It merely makes it unusual to look at. I suspect that the 1-2 week period that most recommend for dietary treatment just provides an opportunity for normal healing/scarring to occur. Octreotide should be given as well because it may decrease overall lymphatic output. Lower output accelerates closure because the amount of scarring needed to close the smaller hole is less.

Interventional radiologists have attempted embolization and needle maceration of the ducts, but the few of these described have been unsuccessful. This is not recommended.

If closure is not achieved in two weeks, then consideration should be given to surgical ligation of the leaking duct. This structure is small and thin-walled, and not the easiest to see. Fats should be administered via NG (olive oil and cream have been described) at the start of the operation to stimulate chyle production. This allows easier identification of the leak site intraoperatively. Suture ligation, clipping, or both can be used to stop the leak.

References:

  1. A case of a traumatic chyle leak following an acute thoracic spine injury: successful resolution with strict dietary manipulation. World J Emerg Surg 6:10, 2011.
  2. Blunt rupture of the thoracic duct after severe thoracic trauma. J Trauma Open 3:e000183. doi:10.1136/tsaco-2018-000183m 2018.
  3. Bilateral Chylhotorax after Falling from Height. Case Reports in Surg  article 618708, 2014.